Posttraumatic stress disorder in veterans with spinal cord injury: trauma-related risk factors

Trauma-related risk factors for posttraumatic stress disorder (PTSD) were examined in a sample of 125 veterans with spinal cord injury. Category of injury was found to be the most consistent predictor of PTSD diagnosis and symptom severity with paraplegia predicting more PTSD symptoms than quadriplegia. The occurrence of a head injury at the time of the trauma was found to predict PTSD symptom severity measures, but not PTSD diagnosis. Trauma recency consistently predicted Impact of Event score (IES) and was found to be related to current PTSD severity and lifetime PTSD diagnosis in multiple but not simple regression models. Trauma severity was found to be significantly related to self-reported PTSD symptoms and lifetime PTSD diagnosis in simple but not in multiple regression analyses. Type of trauma, alcohol or other drug (AOD) use during the trauma and loss of consciousness (LOC) during the trauma were not consistently associated with PTSD symptom severity or diagnosis.

The effectiveness of group psychological intervention in enhancing perceptions of control following spinal cord injury

OBJECTIVE

This research investigated the effects of a structured psychological intervention, delivered during hospital rehabilitation, on the perceptions of control in people with spinal cord injury (SCI).

METHOD

A longitudinal study was designed to assess perceptions of control (using an objective measure of locus of control) in SCI persons who participated in specialised group cognitive-behavioural therapy (CBT) during hospital rehabilitation. The treatment SCI group's responses on locus of control were compared with a control group of SCI persons who only received traditional rehabilitation services during their hospitalisation.

RESULTS AND CONCLUSIONS

Mean locus of control scores were not high (i.e. external) for both groups and there were no overall group differences on locus of control responses across time in comparison to the control group. However, subjects in both groups who initially perceived life as externally controlled were extracted to form subgroups. The members of the subgroup who received CBT were significantly more likely to feel in control of themselves 2 years post injury compared to similar persons in the control group. Furthermore, an external locus of control was significantly but mildly associated with depressive mood 2 years after the injury. This research suggests that the provision of a structured psychological program in the rehabilitation stage will be beneficial for many SCI persons who feel that they have little control over their lives.

Quality of life of spinal cord injured patients in Taiwan: a subgroup study

The major purposes of this study were to assess the quality of life (QOL) of spinal cord injured patients, and to assess the possible factors affecting the QOL. The survey was conducted from 1992-1993 by mailed questionnaires to members of Spinal Cord Injury Association of the Republic of China. There were 347 quality responses with the mean age of 37.5 +/- 10.2 years old and the mean duration of illness of 7.8 +/- 6.8 years. The questionnaire included five domains, physical mobility, environment-transportation, psychosocial adjustment, education and economics for a total of 39 items. Each item contained a rating of 'importance' and 'satisfaction'. The quality of life index (QLI) was calculated by multiplying the satisfaction score with the importance score, then dividing by the possible highest score. The major results included: (1) the subjects had mild to moderate dissatisfaction with most items in five domains except psychosocial adjustment: (2) quality of life in those with complete tetraplegia (QLI = -0.41) and incomplete tetraplegia (QLI = -0.31) was significantly lower than that of those with complete paraplegia (QLI = -0.13) and incomplete paraplegia (QLI = -0.04); (3) both the severity of injury and the post-injury working status were the major factors affecting the life quality of spinal cord injured patients in Taiwan.

Intellectual status of children with cerebral palsy after elementary education

Using Wechsler Intelligence Tests, we compared the intellectual status of children with cerebral palsy (CP) immediately before and 2 years after entering school. Verbal and performance IQs could be assessed for 23 children with spastic diplegia but only verbal IQs in six children with spastic quadriplegia. Performance IQs were much lower than verbal IQs in both the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and the Wechsler Intelligence Scale for Children-Revised (WISC-R) in children with spastic diplegia. After schooling, verbal IQ was significantly increased but there was no change in performance IQ, thus, the difference between these IQs became more pronounced. When comparing the school class types, the verbal IQs of children studying in ordinary classes became statistically higher than those of children in special classes. In contrast, since the increases in mean performance IQs were greater in children in special classes, the differences between these IQs became more pronounced in children studying in ordinary classes. We also found that although verbal IQs were lower for quadriplegic children than for diplegic children at preschool age, there was no difference after 2 years of schooling. These results underline the importance and benefits of appropriate education for children with CP.

[Treatment of patients with thromboses of the basilar artery and locked-in syndrome. An ethical dilemma]

Decisions regarding the extent of treatment of severely ill patients can be an ethical dilemma when life-prolonging intensive care contradicts the goal of avoiding unnecessary suffering on the part of the patient. Here we present the results of a written survey of physicians on neurological intensive care units in Germany regarding the treatment of patients with basilar artery thrombosis and locked-in syndrome. 52% of the 93 physicians who replied advocated not treating severe infections with antibiotics, 38% were in favor of stopping intensive care. In contrast, 55% recommended intubating the patient in the presence of swallowing disturbances and imminent aspiration. 58% were in favor of discussing these problems in detail with the patient, and 87% advocated discussing them with relatives. Nearly all physicians (97%) recommended using adequate amounts of opiates and benzodiazepines. In very rare cases, 99% would agree to the use of passive euthanasia and 19% to active euthanasia. These findings illustrate the current disagreement on some of the important treatment decisions among physicians on neurological intensive care units. An open exchange of views on these questions could facilitate the appropriate consideration of ethical matters in the treatment of these patients.

Neuropsychological assessment after extremely severe head injury in a case of life or death

A systematic neuropsychological assessment technique is described for use with severely physically disabled people who may be severely brain-damaged, in an incomplete locked-in state or potentially in vegetative state. The technique allows opinions regarding cognitive state to be statistically based. In the case described, the weight of expert opinion had been that involuntary feeding by gastrostomy tube should be terminated because the patient was functioning at a level little beyond the vegetative state, her quality of life was poor and she was unable to form a view about her present or future circumstances. An assessment approach is described which uses binomial statistics and allows for some variability in responding. Methods of minimizing sources of extraneous bias are also discussed. By use of this technique it was demonstrated that the patient was sentient though impaired, and that her own wish at the time of the assessment was to continue living. It is recommended that neuropsycholgical assessment of this kind should take place in all cases in which withdrawal of treatment is being considered and cognitive ability is not certain.

Exploring quality of life of adults with spinal cord injuries

Measurements of quality of life have been an important research focus in rehabilitation and medicine. Analyses indicated that for 12 persons with spinal cord injury significant quality of life domains identified through a ranking procedure were different from domains identified through small group discussions. If replicated with larger groups, we would advocate direct responses obtained through small group or individual discussions.

Extra pontine myelinolysis in a tetraplegic patient: case report

Hyposmolar hyponatremia (serum sodium < 130 mmol/l) is a common phenomenon in the spinal cord injury (SCI) patient population and in most cases, it is of relatively little consequence. However, rapid correction or over correction of hyponatremia (a change in serum sodium > 25 mmol/l within 48 h) has been linked to Central Pontine Myelinolysis (CPM) and Extra Pontine Myelinolysis (EPM), usually along with other recognized predisposing factors. We report the first case of isolated Extra Pontine Myelinolysis in an SCI patient without any of the recognized predisposing factors, following correction of hyponatremia. The signs and symptoms of Extra Pontine Myelinolysis were not very remarkable in our patient because of prior spinal cord injury. The diagnosis was confirmed by the typical finding of myelinolysis in the basal ganglion region on MRI. Hyponatremia occurs frequently in the SCI patient population, thus placing them at increased risk for Extra Pontine Myelinolysis. Therefore, we emphasize the importance of watching for this entity during the management of hyponatremia in the SCI patient population and recommend the use of MRI scans to confirm the clinical diagnosis.

A rational approach to long-term care: comparing the independent living model with agency-based care for persons with high spinal cord injuries

Two groups of individuals with high level tetraplegia (C1-4) were compared with respect to the model of personal care assistance used. The study was undertaken to determine whether a finite population with severe disability had differences in health status, costs and perceived quality of life, relative to whether they used agencies for their care, or hired, trained and reimbursed care givers independently. A survey, which included demographics as well as portions of RAND-36, LSI-A, PIP, PASI and CHART was used. Telephone interviews were held with 29 individuals who received their care through an agency and 42 who managed care independently. Chi square, 't'-tests, and multiple regression analysis were used to control for potentially confounding group differences. The self-managed group demonstrated significantly better health outcomes, with fewer re-hospitalizations for preventable complications. They experienced better life satisfaction and significantly lower costs. Although those who used an independent model of care-giving received significantly more hours of paid assistance, the average annual cost of care was significantly lower for each individual. In addition to reducing the financial burden on the individual and society, self-managed care seemed to diminish the emotional burden borne by these individuals.

The functional independence measure in spinal cord injured patients: comparison of questioning with observational rating

Functional independence measure (FIM) is becoming widely used for all aspects of disabling diseases including spinal cord injury (SCI). It is recommended that it is rated by trained clinicians familiar with the patients. We aimed to compare the ratings of those patients who were questioned with those who were observed in a simulated environment. Fifty patients with SCI were included in the study. They were all FIM rated by the same clinician, first by questioning and then by observation. Although observational rating took much more time than questioning there was a very strong correlation between these two different rating methods. We can conclude that questioning SCI patients could be used as a valuable and quick way to assess the functional level of such patients. Although this does not exclude observational scoring that was generally higher and more motivational for the patient.

Acting on a living will: a physician's dilemma

The implementation of a living will can give rise to ethical dilemmas for the patient's family and the health care professionals involved. The case reported here raises questions about the right of patients to self-determination, the importance of quality-of-life considerations in treatment decisions and physicians' obligations with respect to the implementation of living wills. Physicians should ensure in advance that the instructions set out in a living will are unambiguous and should bring to the patient's attention any ethical difficulties that they foresee in carrying out those instructions.

Acquisition and functional use of voice output communication by persons with profound multiple disabilities

The acquisition and subsequent functional use of communication skills by persons with profound mental and physical impairment using a voice output communication aid (VOCA) was evaluated. Initially, a graduated guidance and time delay procedure was used to teach three individuals to use a VOCA in response to a trainer's specific request. Results indicated that all participants increased their correct VOCA activations in response to specific requests following training. Probes also indicated that participants effectively used the VOCA after training to request preferred items in a variety of settings. The functional utility of VOCA skills was supported by a survey of individuals unfamiliar with the participants. This survey indicated that those surveyed could better understand the participants when they used a VOCA. Results are discussed as to potential advantages of VOCAs relative to other augmentative communication options for persons with multiple disabilities. Future research directions are discussed, focusing on strategies for promoting a broader set of communicative interactions using VOCAs.

Psychosocial issues following serious head injury: a case study of an adolescent girl

This article is a case study of an adolescent girl who sustained a serious head injury following an attack by strangers. The head injury caused an epidural hemorrhage that exerted pressure on her brain stem and resulted in spastic quadriplegia. In this case, the major issues in rehabilitation were the patient's ability to learn to communicate and normalize and gain control over various aspects of her life. Because of the lack of a specialized rehabilitation setting for children and adolescents, rehabilitation took place in an acute care setting, which makes this story unusual in many ways. Staff issues were significant because of the nurses' inexperience with rehabilitation issues and because of the setting. This article describes the primary nurse's experience with this patient over several months. During this phase of rehabilitation, psychosocial issues were a major concern. Fifteen months after rehabilitation began, the patient moved back home and returned to high school. She communicates by using a computer and by using her eyes, and she uses a wheelchair. Despite everything, she is determined to get better and to prepare herself for the future.

Childhood onset of spinal cord injury: self-esteem and self-perception

The effects of spinal cord injury in childhood upon later psychological adjustment were investigated by comparing a group of 86 people injured as children with a control group (matched for time since injury and level of injury) of people injured as adults. It was hypothesized that adolescence is a crucial period in psychological development and that the effect of spinal cord injury on body image, self-concept and social relationships during adolescence will have a long-term negative effect on psychological well-being. However, on overall measures of depression, self-esteem and self-perception, there were no significant differences between the experimental and control groups. Furthermore, there were no significant differences between paraplegics and tetraplegics, between men women, or between those who were involved in a significant intimate relationship and those who were not. These findings support previous research which has suggested that organic variables, such as age at injury and level of injury, are not predictive of long-term psychological adjustment.